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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 694 iii
House of COMMONS
TAKEN BEFORE the
Communities and Local GOVERNMENT COMMITTEE
The role of local authorities in health issues
Monday 3 December 2012
COUNCILLOR ANTHony Devenish, COUNCILLOR Nick Forbes, Liam Hughes and COUNCILLOR Mary Lea
Kim Carey, COUNCILLOR Roger Gough, Dr Mike Grady and COUNCILLOR Ernie White
Evidence heard in Public Questions 167 270
USE OF THE TRANSCRIPT
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Taken before the Communities and Local Government Committee
on Monday 3 December 2012
Mr Clive Betts (Chair)
Examination of Witnesses
Witnesses: Councillor Mary Lea, Cabinet Member for Health, Care and Independent Living, Sheffield City Council, Councillor Anthony Devenish, Cabinet Member for Public Health and Premises, Westminster City Council, Councillor Nick Forbes, Leader, NewcastleuponTyne City Council, and Liam Hughes, Independent Chair, Oldham shadow Health and Wellbeing Board, gave evidence.
Chair: May I welcome you all to our third evidence session of the Inquiry into the role of local authorities in health issues? Just before I come on to our first witnesses, we have a new member of the Committee, Andy Sawford, and at the beginning we ask new members to make a declaration of interests for our records. So, Andy, over to you.
Andy Sawford: Thank you, Chair. I am in the process of resigning from a number of posts, including my trusteeship of the Centre for Public Scrutiny and a number of posts related to my previous employment as the chief executive of the LGiU.
Q167 Chair: Thank you very much indeed for that. That is on our records and noted. Thank you all for coming this afternoon to give evidence to us. You are most welcome. For the sake of our records, please say who you are and the organisation you are representing. Thank you.
Councillor Anthony Devenish: Anthony Devenish, Cabinet Member, Westminster City Council.
Councillor Nick Forbes: Councillor Nick Forbes, Leader of Newcastle City Council and also a member of the Local Government Association’s Children and Young People Board.
Liam Hughes: I am Liam Hughes. I am the independently appointed Chair of the Oldham Health and Wellbeing Board and retired from the LGA at Christmas.
Councillor Mary Lea: I am Mary Lea. I am a Cabinet Member in Sheffield City Council.
Q168 Chair: You are all welcome this afternoon. Clearly, you have a range of different backgrounds, experiences and ways in which you are doing things; however, if there are things that one of the witnesses says that you get asked about and totally agree with, you do not have to repeat your agreement. Just say you agree, and then we can get on to make sure we cover all the issues in front of us this afternoon. We begin with something that we picked up from the evidence from Sheffield City Council. They talked about local government’s history of placeshaping and that general role, and how bringing public health within local government and working together could help combine more effectively the expertise that local authorities and the NHS have. We have a lot of evidence of partnership between local government and the NHS in recent years. Why do you think the proposals we have now for local authorities to work at, with their placeshaping role, might be more successful in the future than we have been in the past at these various partnership arrangements?
Councillor Mary Lea: I think in Sheffield we have had some joint posts with public health and the Council for a couple of years. Our director of public health and the public health consultant in children’s services has been a joint appointment, and another one was appointed a couple of years ago, the public health consultant, as a joint post. Lots of people say that public health’s place is with local government rather than with the Health Service anyway, and many, many years ago, before my time, obviously, that is where it sat-in local government. In terms of Sheffield, and I am sure other local authorities as well, we are a public health council, and everything that we do, you could say, will benefit the public health of the citizens of Sheffield, whether it is in terms of the work we do on employment, the work we do in our communities, or the work we do in our environmental services. It is all to do with public health, and I think public health from the PCT coming into Sheffield will bring their particular expertise in terms of how they can gather information, analyse evidence and so on and so forth, and give that to the Council. The way we have organised the public health staff in the Council is to have the director of public health sitting in a hub-I am not sure if that is what we are going to call it now-and the consultants then sitting in each of the directorates with the staff that they manage underneath them contributing their expertise to that particular directorate within the Council. But I think Sheffield City Council has always been, as I said before, a public health council, whether it is at a very local level in terms of regenerating parks in local areas with friends’ groups and so on, to the big new City Deal that we have just gained from Government.
Liam Hughes: I would just say that we are in a slightly different world. We are in hard times, and the partnership for a health and wellbeing board is much tighter than anything we have seen before. I think there is ample evidence of partnerships being loosely formed and failing to achieve very significant changes in outcomes for people, and this time, I have to say, it feels different. There is more focus and there is more of a sense of commonality, say, between CCG members and councillors in the health and wellbeing boards that I see, not just in Oldham but in the perhaps 18 or 19 others I am working in as well. So I am optimistic despite the evidence of history.
Councillor Nick Forbes: Health, be it good or bad, does not exist in a vacuum. It does not exist in isolation of the wider social, environmental and economic context that operates in society, and so, if we think about improving health, we have to also think about the wider determinants of health. I think that is why the new system is different, because local authorities are able to operate in the social realm, in the economic realm, in the environmental realm and in the realm of public policy, whereas I think many of the partnerships that we had before were often about the integration of health and social care service delivery. So this feels to me to be qualitatively different, having public health as part of the local authority function, because it gives us the opportunity to think more broadly about what Derek Wanless called the art and science of changing society. I think it is the art, science and politics of changing society for the better.
Councillor Anthony Devenish: I would agree with most of what has been said. I think we have been well prepared. We started 18 months ago in terms of our health and wellbeing board, and I think the crosscutting nature of some of the issues that have already been touched on is very important, and the preventive side particularly. To give you one example, we have made sure that my portfolio does not just cover public health; it covers licensing as well, and clearly there are crosscutting issues there. For example, on shisha pipe smoking, which is a big issue in central London, we want to make sure that we work with the community to ensure that we do alleviate those issues, because obviously smoking shisha is a lot worse than smoking normal cigarettes. There are a number of issues we are looking at and working on; there may be pilots on specific issues and attacking those. And we are more local, I think, than the NHS, with the greatest respect to them.
Q169 Chair: You have given us practical examples, I think, in your evidence of things you intend to do in your new role on unemployment, dentistry and adult social care. Do you just want to say a little bit more about those and just highlight maybe what the public of Westminster can see in a couple of years’ time being different from the way things have been in the past?
Councillor Anthony Devenish: We are still working on all the details about each of those, but, for example, we are making sure that we will be focusing particularly on dentistry in the schools where there are issues of deprivation. But there are a number of things we are working on in terms of the evidence.
Q170 Chair: Would the rest of you give one practical example of things that you might be looking at where people could see a significant change?
Councillor Nick Forbes: We are having a very different approach to alcohol policy. The licensing legislation has been to all intents and purposes marketled, and yet what we have seen in the health statistics is an extraordinarily alarming rise in liver disease and liver cirrhosis, and a ticking time bomb, I think, for future generations of liver problems related to alcohol. That is why instead of simply looking at alcohol treatment services, which is dealing with the problem too late, we are looking at the environment in which people think about and consume alcohol. That includes looking at the availability of it through not just pubs and clubs but also off-licences. It is about looking at the affordability of it in terms of the price-and we are campaigning as a council for a minimum unit price of alcohol-and also the desirability. This I think is one of the new areas for public health to get into, but we are faced every day in our lives with social norm change behaviour, which is called advertising, and yet nobody is countering that. I think there is a role for public health in terms of changing social norms around the way that we think about alcohol, in much the same way as social norm changes come about through the work done in tobacco control. That is just one example where local authorities will be able to take a much more holistic approach, bringing together their range of regulatory services and other functions in a way that the Health Service, when it provided public health functions, just was not able to do.
Liam Hughes: I have two very quick examples. The first is the focus on the emotional wellbeing of very young children and also on early speech and language. Over a period of a few years we should be able to see those children more ready for school at age four and a half or five.
The second example I will give is recognising that the support for the carers of people with dementia is critical to making the whole system hold together. That has been a particular major focus, and whilst we have put the first building blocks in, we are in the middle of a very interesting debate about which is the most effective way of providing support to those carers, supported by the Alzheimer’s Society and others.
Councillor Mary Lea: Over the course of this last year, we have had a task and finish group of local members looking at what the public health service does that is coming over to the Council. We have looked at that in terms of just the work that they do and also what priorities we might have as members in changing some of that work. We would like to see rather less work done on getting people to change their lifestyle, and more work done on looking at the root causes of ill health-some of the barriers that people have in changing their lifestyle. We could say we have two parts to Sheffield: we have the southwest of the city, where people have taken on the lifestyle messages and are living longer and healthier lives. They have taken on all the health messages and are doing what we exhort them to do-take responsibility for their health. But in other parts of the city, for some reason-because of, I am sure, the barriers that lie there-it has proved very difficult for people to take on those lifestyle messages. So we want to get to the root causes of some of the barriers that are preventing people from making those changes that will have longterm benefits for them. That would be one of our priorities.
Another one is to do with what we can do as a council to lobby Government in terms of some of the big health issues that we face: for example, obesity, how food is produced, how food is manufactured, how food is advertised and sold. I think there are some changes there that only Government can make. We also want to look at some of our bylaws to see what we can do in terms of where food outlets are placed: are they near schools? Do we want some food outlets, takeaways and so on, in certain places? We want to look at what we can do about those sorts of issues.
We think it is really important to focus on early life, nought to three, that age group; that is obviously vital.
Chair: That is one or two examples, which is fine. We will probably come on to some of those issues in a minute.
Q171 John Stevenson: The health and wellbeing boards are central to the changes, but under the legislation there is limited statutory prescription as to membership. What I would be interested to hear from each of you is who is going to chair in your particular area, what is your membership over and above the statutory requirement and how will you have future appointments?
Councillor Anthony Devenish: Our Leader chairs our Board, and I think that is a good example; it is not me as just a cabinet member but the Leader of Westminster City Council, Councillor Philippa Roe, who chairs it.
In terms of the membership, we are still considering exactly how wide that is, but we already have a number of both voluntary sector and NHS individuals involved. We are triborough in Westminster, so we are also involved in the Royal Borough of Kensington and Chelsea, and Hammersmith and Fulham, so, again, they are all involved in the process.
I would not want to preclude the future. We have an open mind on it at the moment. We are 18 months into our Board running shadowwise, but as to how we get members, I personally have an open mind; if somebody adds value, we would certainly consider that organisation for the Board.
Q172 John Stevenson: Will the additional membership in your case always be with the Council rather than the Board itself? Once the Board is formally constituted, would it choose successor members or would it always be the Council that decides what the membership is?
Councillor Anthony Devenish: I think I would probably have to reflect on that.
Q173 John Stevenson: Are you going to have a limit on the number as well or be openminded?
Councillor Anthony Devenish: I think we are openminded about that.
Councillor Nick Forbes: In Newcastle, I chair the Wellbeing for Life Board, as we call it. As Leader, I also chair the Council’s Cabinet. It was a very explicit decision to do both, because I think the Cabinet is the internal decisionmaking arrangement within the Council, and I have constituted the Wellbeing for Life Board as the major partnership within the city, so I am one of the pivotal points between inwardly looking to the Council and externally looking to partnerships within the city.
The way that we have structured the Board is around what we are calling a Newcastle Future Needs Assessment, which is a successor to the JSNA-joint strategic needs assessment. The JSNA process defines particular areas of need in either health or social care. The Newcastle Future Needs Assessment process that we are adopting looks at the whole lifespan in the city of the population, so from cradle to grave. The idea is that, if we can use our partnership arrangement through the Wellbeing for Life Board to determine at which points in people’s lifecycles they are held back-
Q174 John Stevenson: I just want to concentrate on the membership rather than what it is going to do.
Councillor Nick Forbes: Yes, but the reason I am explaining this is because it explains the rationale for the membership. We therefore know the points in people’s lifecycles where they perhaps are held back from achieving their potential, which means that we can target resources, which means that over time, using shared analysis between public sector agencies, we can start aligning resources around that. That starts to inform the wellbeing strategy that we are developing, and the wellbeing strategy itself will determine the future membership of the Board, depending on the areas that it needs to focus on.
Q175 John Stevenson: So what you are saying is that you think your Board will continuously change.
Councillor Nick Forbes: Yes.
Q176 John Stevenson: And who will determine that change? Will it be the Council or will it be the Board itself?
Councillor Nick Forbes: Ultimately, it will be a committee of the Council, under the governance arrangement, so it will have to be ratified by Council, but as a partnership I would not expect to make changes without reference to the wider city.
Q177 John Stevenson: And would you put a limit on the number of members of the Board?
Councillor Nick Forbes: I do not think big boards work. We are currently thinking about whether some kind of broadbased board membership but with a smaller executive structure would work in terms of making sure that we cover day-to-day business. The other thing we are looking at is, to avoid confusion, thinking about a public sector agencies board that would look at issues around service delivery so that the Health and Wellbeing Board can focus on the strategic picture.
Q178 John Stevenson: So you would envisage trying to keep the Board as small as possible.
Councillor Nick Forbes: I would try to keep it as small as possible. It is that paradox of people feeling included and involved but not necessarily having a seat at the table.
Q179 John Stevenson: Mr Hughes, you have rather a different set-up, because you are an independent chair.
Liam Hughes: Yes, I am independent simply because the Leader was new and there were lots of changes on the NHS side and the local government side simultaneously. My job is to steer the Board in shadow form into existence, and at that point the Council will reflect on how it wants the Board to be chaired.
One thing we did was have a look at the skills, knowledge and experience of the people on the Board against what we thought were the emerging themes from the JSNA and from consultations, and we were really short of people who understood regeneration and housing in depth. We have coopted from the social landlords an able member to the Board not as a representative-and that is very clear-but as a full Board member, because of that background and skill that we felt we were missing.
Q180 John Stevenson: Is it the Board doing that rather than the Council?
Liam Hughes: The Board identified the gap. I then had a conversation with the Council Leader and Chief Exec about filling the gap. The decision is the Council’s, so that is how it has worked in our context.
Councillor Mary Lea: In Sheffield we have one CCG, which is very helpful, and we decided early on that four GPs, the Chair of the CCG and three others would sit on the Board-and four Council members.
Q181 John Stevenson: How many Council members?
Councillor Mary Lea: Four elected members. The Leader of the Council and the Chair of the CCG are cochairs of the Health and Wellbeing Board. I sit on it, obviously, because my portfolio is health, the Cabinet Member for Children’s Services and the Cabinet Member for Housing. The reason we chose housing is because we think it is so fundamental to health that we need a direct link in to the Cabinet Member and the housing services that his portfolio provides. That is how we have made up the Board.
We made a decision that at the moment we will not have providers sitting on the Board. We have had lots of people beating on the door saying, "Please give us a place on the Board," but we have decided that there may be conflicts of interest with providers, and we want to take a very strategic view from the Council and the CCG perspectives of health and wellbeing across the city. I think the plan will be in time to have subgroups, where we will call on the expertise of other people in the city, whether it is housing, social landlords or the trusts or whatever, to do specific pieces of work or to advise us.
Q182 John Stevenson: Out of curiosity, none of you have decided on an absolute number, so in the future it would obviously be at the discretion, I think, from what you have all said, of the Leader of the Council of the day or the Council to appoint additional members. Effectively, what you are saying, I am concluding, is that the Council would have a very, very strong influence on the direction of this board and should there be a difference of opinion on the board and there was a vote, quite clearly it would be, to a very large extent, the ability of the Council to determine the final decision. Would that be correct?
Councillor Anthony Devenish: I would not quite put it like that, but I guess, effectively, governancewise that is probably the case.
Liam Hughes: I wonder if I can just say two quick things. One is: if it comes to a vote too often, we have probably missed the plot. We are probably in the wrong place.
The second thing is it feels to me very different in large counties and in unitary metropolitan authorities, and I have seen some large counties set up a very large board but then pay very little attention to the executive and working groups that hang underneath it. That is because of the sense that the district councils are very important players in this, and we have seen a number of different systems, from a federated system of one or two representatives from the districts through to all district councils having a seat on the board, and the numbers can vary between about 20 and up to 30odd.
Q183 John Stevenson: Do you envisage a difference between the unitaries and the twotier authorities in terms of the success of this?
Liam Hughes: I do not see why there should be a difference in the success if the design is functionally sorted out in terms of those two layers. I cannot say that I think that large county boards are heading towards being unsuccessful, because that is not my experience of them up to this stage.
Councillor Nick Forbes: I would just raise a potential inconsistency in Government guidance here, because I think what we are reflecting on is the importance of local democratic leadership in the process, and yet the Government has specifically barred councillors from being members in CCG boards. It just feels to be an inconsistency that needs not be the case.
Q184 Andy Sawford: Would it be your view that councillors should sit on clinical commissioning group boards? What would be the advantages of that?
Councillor Nick Forbes: Certainly our experience in Newcastle is it has been invaluable in terms of simply being a channel of communication between the Council and the CCG. So, in my case, I have two deputy cabinet members who sit on our two CCG boards. They are able to relate the priorities of the Council to the CCG Board and relate the priorities of the CCG Board back to the Council. Severing that link for no apparent, obvious purpose is a mistake.
Q185 Chair: On that point, we went to Kent to look at what they were doing there. What came out very clearly was that the overall strategy was very much being driven by the County Council along with the districts on subgroups, but the commissioning groups were, in the end, meant to be implementing their commissioning according to the overall strategy. Is that what is happening in your areas as well?
Councillor Nick Forbes: I think we have a way to go on that. My experience of the CCGs is that, firstly, a lot of the time that they have spent over the last six months has been on the authorisation process, and therefore they have just not had the capacity to get involved in the wider discussions in the city about the future vision and direction. Secondly, I think CCGs are working within a very nationally prescribed framework, and therefore have very strong clinical delivery targets that they have to meet, and I think that limits their ability to operate within a partnership environment, particularly in terms of deployment of resources. There is a fundamental issue here about the balance of power between CCGs and providers within the NHS. The gravitational pull of the big foundation trusts is such that, if you look at the allocation of resources between prevention and treatment, you see it is almost all skewed towards treatment within the NHS. I would question whether many of the public health resources that we are thinking about inheriting in the future are fit for purpose.
Q186 Chair: We will come on to that point in a second. Anything else?
Councillor Mary Lea: Obviously, we have our joint health and wellbeing strategy, and we will look at our commissioning plans based on that and challenge each other when necessary, but that is the fundamental basis of how we will go forward. As part of the work of the Health and Wellbeing Board, we have five other strands of work that are ongoing with GPs and members taking a lead: health, unemployment, care closer to home, emotional resilience and mental wellbeing, children’s services-looking at early years-and food and activity as well. Those five work strands are ongoing at the moment, and they will feed into the strategy as we go along and into the commissioning plans.
Chair: So they may influence commissioning plans as well. Okay, that is fine.
Liam Hughes: Every one of our strands of work has a GP attached, and they are enthusiastic. The real success for me was shown in Fair Fuel with the building up of the cooperative arrangements, which the GPs supported and put cash on the table for. That was a sign that things were changing.
Chair: Getting GPs to put in cash is certainly a step forward.
Councillor Anthony Devenish: We have not found any particular issues, because we have a programme board that is chaired by a chief executive and we have the same kind of work streams as the others. The others I am sure have contract and commissioning, finance and procurement, communications, HR, information governance and IT, and estate and facilities. We have a robust risk register and we have been going for quite a while now, so I think we are fairly confident.
Q187 Bob Blackman: Turning to the vexed issue of funding, obviously the Advisory Committee on Resource Allocation have come out with a draft interim funding formula under which, uniquely, all four of you lose, so I assume you are not very happy about that. As I understand it, it is based on the under-75 standardised mortality ratio. Presumably there are other factors that you would like to see included in the formula.
Councillor Anthony Devenish: Absolutely.
Q188 Bob Blackman: At Westminster you lose most of all, so there must be some things that you would like to see included.
Councillor Anthony Devenish: The two biggest examples are that about 35% of our spend is demandled on open access sexual health services and around 39% is demandled drug and alcohol services. To put it in layman’s terms, obviously Westminster has about 200,000 residents, but we have threequarters of a million people coming into the city every day and it is those younger people who are coming in to enjoy our city who also, dare I say it, do other things. I would not say they are a drain on resource-that would be the wrong word-but we have to allocate resource for those individuals.
Q189 Bob Blackman: Westminster is a unique case because of the transient nature of visitors, but should those visitors not be looked after by the local authorities where they live rather than by you?
Councillor Anthony Devenish: Well, no, because the reality is most of those people who come out and socialise often work here, and therefore they are going to be here during the day getting the medical resources they need. Wherever they come from, they may only sleep there. They spend as much or more time in Westminster as they do in their own communities, so that would be more feasible for them and for their businesses and for the wider national interest.
Q190 Bob Blackman: Apart from parking, how else do you charge them for the services you provide?
Councillor Anthony Devenish: Hopefully, through the DH agreeing to the suggestions that we have written to them about and asked for.
Councillor Nick Forbes: We suffer from a not dissimilar phenomenon, which is that the number of people who turn up and use Newcastle’s services is far higher than the number of Newcastlebased residents. Similarly, in the use of sexual health services, use of drug and alcohol services, homelessness support, we tend to find we have higher levels of need than our base population simply because of our position as a city that people gravitate towards.
Q191 Bob Blackman: So what factors should be taken into account for this funding formula?
Councillor Nick Forbes: My understanding is that the funding formula has been shifted towards age, whereas I think that is a separate argument. Indeed, the Public Health Outcomes Framework clearly says it is about increasing the length of life and tackling health inequalities, and yet the funding that is there to tackle all of the areas of deprivation that prevent people from living a long and healthy life is most at risk and is being cut back. I think there is a separate argument about provision of services for an ageing population from one of providing public health services that enable people to enjoy a long and happy life, and yet they have become confused within the argument about the funding formula.
Liam Hughes: I would just say one very simple thing. If we are listening to Sir Michael Marmot, we are looking at the 100year scenario. That suggests that we invest early on and, if we are doing that, the formula is not fit for that purpose.
Q192 Bob Blackman: So what would you like to see included in that formula?
Liam Hughes: This is a very small thing in the total picture, but I would want to look at how well children are doing in terms of their speech and language development as well as their emotional development. These are tricky to count, and I know that the technicians will say, "It is very hard to get to readiness for school," but I am looking for that. That is what I would really want: to make sure that the Oldham children went into school with a fair chance.
Councillor Mary Lea: I would agree with everything that has been said, but I would just like to point out as well that we are facing significant budget cuts in Sheffield, as other councils are, particularly in our Early Years Service. Much of the work that the Council does, as I pointed out before, is public health work, and the resources are now being cut for some of the services that provide that kind of work. Although public health will bring some resources with it, it will fill a gap.
The welfare reforms that will kick in next year are going to cause significant problems and difficulties for already very vulnerable and deprived areas. There is £180 million that will probably go out of Sheffield’s economy and out of people’s pockets, out of families and out of communities, so that is going to be very difficult. We have some significant communities in Sheffield that are deprived and also we have lots of migration into the city, particularly from Eastern Europe. These are people who have come from extremely deprived circumstances in their own country and have very great difficulty adapting to the communities they are going to live in, which causes some difficulty. So we have all of these cuts, we have the welfare reforms, and although we will have the resource of public health and the expertise, we are not starting from where we were a year ago and building on that, so it is going to prove extremely difficult.
Q193 Bob Blackman: Where do you stand on ringfencing and the money for public health being ringfenced: for or against?
Councillor Anthony Devenish: I think it has been a very simple way of doing it in the past, and I do not particularly feel you need to ringfence it. At local level we can spend the money we get whatever the figure is.
Q194 Bob Blackman: But suppose in Westminster you are going to take a potential cut of 57%, according to the figures we have. So, your Leader is going to say, "You are not getting any more, so you have to do public health with the money you have and, funnily enough, I need some of that money for other purposes."
Councillor Anthony Devenish: To some extent, but we would like to work out our overall budgets. It is the overall pot you have, and obviously we want to put our begging bowl out, to put it bluntly, but we do not really need to ringfence it. In the old days, wherever it was ringfenced, you had lots and lots of people having to administer exactly what you spent everything on in various budgets; that is not a way we want to go back to.
Q195 Bob Blackman: Okay. Nick, where do you stand on ringfencing?
Councillor Nick Forbes: Instinctively, I do not think ringfencing is a good idea. I would like to see simply the resources of the Council being considered as public health resources.
Q196 Bob Blackman: As I understand it, there would be nothing wrong with you deciding to take some resource from other purposes and putting it into the budget.
Councillor Nick Forbes: Except the experience that we have had over the last few years of the Government deringfencing budgets at the same time as cutting them means that I do not think it would be a sensible thing to do at the moment, because public health colleagues need some certainty that public health will continue to be seen as a national priority. One of my concerns is that, if it is deringfenced entirely immediately, it will simply disappear into local government in the context of the massive cuts we are facing.
Q197 Bob Blackman: Would you prefer a placebased budgeting system rather than ringfencing?
Councillor Nick Forbes: Absolutely, yes.
Bob Blackman: Presumably, Anthony, you are the same.
Councillor Anthony Devenish: At the end of the day, it is the money you get.
Bob Blackman: And how you use it.
Councillor Anthony Devenish: Yes, not the ringfencing versus nonringfencing.
Councillor Nick Forbes: There are far too many turf wars between adult social care, children’s social care and health service delivery. I agree entirely; what we need is a total-place budget approach that looks at the whole system from a population and people perspective rather than an organisational perspective.
Q198 Bob Blackman: Can I get Liam and Mary’s view?
Liam Hughes: What I would add to this is that I think ringfencing will serve a purpose for a period of time, and that purpose will be to give confidence to those staff who are transferring into local government.
Q199 Bob Blackman: So, if it is interim, how long should it last?
Liam Hughes: I think it should last for five years, but that is a personal view.
I think there is a slightly different set of questions around substitution. Substitution is where the local authority is running some public health service and is being hit in the way Nick has described, and it chooses to take that into the ringfence because it is part of the function that has been transferred. I think there are subtly different arguments about each of those.
Councillor Mary Lea: I agree. I think there will be some pressure in terms of what the council delivers in terms of public health activity and what the public health service already delivers, which is very similar, so there will be pressures there. But we would like to see maybe more powers devoted to local government so that we can tackle more of the social determinants of poor health and inequalities. In particular, maybe we are looking at the Work Programme. That may be something that we would like to see devolved down to local authorities, because we think we can maybe make a better job of that than is currently happening. We know our local people and our local communities; we know how to get in there and address those issues. Also, in terms of any welfare savings that are achieved by getting people back into employment, maybe some of that money should be then brought back to the local authority so that we can again use that to tackle some of the social determinants of ill health.
Bob Blackman: You can recycle it. Thank you.
Q200 Andy Sawford: I sense a difference of view. Anthony, your perspective is that community budgets are the right thing but, Nick, you were arguing for both. It seems to me that if this Committee were to make a recommendation that ring-fences should remain for a period, then-you were juggling with it in your answer-that does somewhat argue against the case for total-place community budgets. So I would just put it to you that they are contradictory positions. To your point about the turf wars, if you want central government to be the grown-up to resolve the turf wars, then it will be. But if you want to make the argument to have total-place community budgets, then you must do so very strongly with the down side of the ring-fence. We will need to take a position on this.
Councillor Nick Forbes: There is an idealistic solution, which is about simply looking at the resources available in an area and deploying them according to the need of the local area. That is my vision for how things would work. That is how we are structuring our Wellbeing for Life Board. That is how we are putting in place the Newcastle Future Needs Assessment. We are trying to get to that point. There is a series of tactics, though, to go through first, which recognise that we do not live in an ideal world yet and there are politics at play. I do not mean big "P" politics; I mean small "p" politics, between different organisations. There are certainly politics around the funding formula, and there are issues around needing to instil confidence in people who are transferring from the NHS to local authorities that public health is treated seriously across the board and not just by those local authorities that are saying that they are treating it seriously. So, for me, there is a kind of "this is where we want to get to" argument, but there is a "this is how we are going to have to deal with it in the short term in the real world" argument as well. That is why I think Liam’s point around protecting the ring-fence for a particular period of time is probably the most pragmatic position in the circumstances.
Q201 Heather Wheeler: I would like to take us towards the practicalities of merging all of this together. How have you found bringing National Health employees into local government and becoming local government employees? I am just wondering if, very briefly, you could give us a quick rundown on how you got on and what issues that brought to bear.
Councillor Anthony Devenish: It is like any major transition: it is how early you start, the fact that you plan it properly and you have twoway communication. We have had a very good reputation and history of the NHS locally anyway in Westminster, and we are just continuing that process. We are TUPEing over potentially up to 38 people. We have our DH here today, and she is working closely with the individuals. By early action you can avoid losing good people, because otherwise they do get concerned about their job security, obviously. As I say, we have been doing this for well over a year, so it is prior preparation-the old cliché.
Councillor Nick Forbes: One of the things we have found quite difficult to get to the bottom of is exactly what is being commissioned by the NHS in public health terms. A lot of the contracts that we have been presented with as public health legacy contracts look to me as though they are more like service delivery contracts that should be mainstream commissioned services rather than public health activity. So I think what it has revealed is a difference of opinion on what public health activity is between the PCT in the old world and local authorities in the new world. I think part of the role that we are having to go through now is to navigate those differences of opinion in a relatively short period of time to come up with conclusions that will match our priorities as a council.
Liam Hughes: I just wanted to talk about culture and the change of culture that comes with entering local government. The LGA with the Department of Health ran a series of workshops for staff working in public health well before the transfer. At first, they did not know that much about how councils operated and they were very pleased to hear from leaders of councils, chief execs and others about that. There was a light-bulb moment when some of them realised that, even under these difficult times in local government, there are far more career opportunities in the local authority than there would be in a small public health department inside a PCT. I think that began to open up different sorts of discussions with those staff, because they bring a skill set that is about public health in the way Nick described it-in the very widest sense.
Councillor Mary Lea: We have had a transition board up and running for quite some time now. I think it started towards the end of 2010, beginning of 2011, and that has been working with the local authority, the PCT and the trade unions to cover the transition process from the PCT into the local authority. That has worked well. We have held a number of induction workshops for staff and we have done an equalities impact assessment-that is ongoing-and staff are moving in. I think some of them were moving into our premises last week. They all started to move in and find computers and desks and you name it. But I think one of the things that has been highlighted for many staff is a big cultural shift, and we should not underestimate how difficult that can be. Intellectually, they might have thought this might be a good move for them, but I think their hearts are with the Health Service, because that is where most of them have been for most of their working life, so they have to make that shift. I think also we need to help them to look and discover the opportunities that are there within the local authority that you certainly would not have within the Health Service. As we have said before, the Council is a placemaker, if you like. We can gather people together. We can get all the organisations within the city. We can ask people to come together to discuss any problem we would like them to discuss and come up with solutions, and public health will have access to all that resource, which I do not think they have had in the Health Service. We have to help people understand those opportunities as well as help them through this difficult time.
Q202 Heather Wheeler: My second question, which sounds like it is going to have unbelievably brief answers-which is good because I have a third question-is that I was wondering whether you were envisaging having problems filling vacancies and if you needed any extra budget to do that. But it does not sound like you are going to have any problems, which is very good news. What do you reckon?
Councillor Anthony Devenish: I think I would rather go back to the demand budget point than this point. I cannot foresee every circumstance, but the demand issue of potentially London Councils saying, "We are losing 57% of our money," is our number one concern at the moment.
Liam Hughes: I think there is a problem. I think we will discover that a significant number of senior public health leaders will take this opportunity to retire, and I am not sure that we are doing enough to prepare the next generation for working in the new context that they will be in.
Q203 Heather Wheeler: That is great. I will do my third and last one, if that is okay. Now that the staff are moving into the local authority world, with much more access to political members and councillors, which they would not have had in the public health service, do you think the priorities that they are going to work to are going to be swayed by public issues rather than time-served knowledge about what they ought to be doing, whether it is addressing smoking, obesity or whatever it is? There is going to be a public issue that the councillors are going to demand they spend their time on.
Councillor Nick Forbes: I think at the heart of that question is the fundamental issue about what the role of public health staff is and who public health professionals are. I consider myself, as Leader of the Council, to be a public health professional because, to me, public health is about improving the quality of life for everybody. I think the role of public health specialists who are transferring is to enable a wider discussion about the things that local authorities can do that will make a bigger difference. That is a crucial point about the integration of public health into local authorities: it is not about a stand-alone department that will come and sit alongside everything else; it is about something that has to permeate. To use an analogy, it is a bit like putting squash in a glass of water. We need it to dilute right the way throughout rather than remain concentrated at the bottom, and occasionally it might need a bit of a stir to do that.
Q204 Heather Wheeler: Good luck with that. Mary, do you have some views on that?
Councillor Mary Lea: I think the most valuable thing that we feel is coming across to the Council is the expertise of the people that are going to come and join us. It is not so much the activity. The activity can be shaped and changed and will change over time. I do work already with public health consultants in the ward I represent. I work with the local public health staff and have worked with them closely over a number of years, including the consultants, so there is that contact already. I think there is a bit of a change in culture, because elected members have an opinion and they will give it. They will say, "These are our priorities," and maybe sometimes it will conflict with what they feel they have always done as health professionals. Obviously, we will prepare them for that, but we do listen to advice, do we not? We do not ignore it, and we can be very helpful to them as well, as local members- extremely helpful to them.
Liam Hughes: I ran a PCT and I just want to say that there were debates and sometimes conflicts about evidence and particular themes that commissioners were wanting to pursue, and that was happening even within the PCT. I think that is healthy, because I think we need to look at the best evidence we can get but also check it out against our intentions and our values and that grey area, where things are not very well evidenced, which is an awful lot of daily life in cities.
Councillor Anthony Devenish: I would say that Westminster has a number of amazing councillors who do specialise in particular areas of local government. There are one or two that specialise in the health area and I think their views are very valid. We are a very diverse council in terms of everywhere from my ward, Knightsbridge and Belgravia, to Harrow Road, which is a very deprived ward, and I think it is right that the clinical experts, who are excellent, interface with the councillors and come up with locally based solutions.
Q205 Simon Danczuk: Concerns have been raised about immunisation and screening services and that began to get me worried about them as well. Then, to add insult to injury, the Chief Executive designate for Public Health England told this Committee, and I am quoting him here, "There is an issue about screening and immunisation. I agree that we would not have invented this system," which caused me even more anxiety. If we start with you, Anthony, have you received assurances from Public Health England that immunisation and screening services will be maintained and local diversity will be considered?
Councillor Anthony Devenish: Well, I think we are having a dialogue on this issue. Because of the churn of the population, particularly in places like Westminster-and some of our wards have a 30% or 40% churn a year-there is clearly the issue that a woman could be on one list in our area and just miss it and then move off somewhere else where they have already done the list for breast cancer, for example. So it is certainly something that we need to give some thought to.
Q206 Simon Danczuk: You guys have been good at it from what I have read previously. You say you are "having a dialogue". We are running out of time; are you a bit concerned like I am?
Councillor Anthony Devenish: I think there is always concern, absolutely, but I always like to look at solutions rather than just saying the word "concern". We need practical solutions at a local level and, yes, we would obviously like them to particularly take account of local factors in places like ours.
Q207 Simon Danczuk: Are you comfortable and confident that everything will be in place and it will be seamless?
Councillor Anthony Devenish: "Seamless" is a great word, is it not? I think we need to keep the dialogue going.
Q208 Simon Danczuk: Okay, fair enough. Nick?
Councillor Nick Forbes: The concern that I have around immunisations and screening is that any period of transition means there is an increased risk that people will slip through the net, and what I have not yet seen is sufficient contingency planning to ensure that that does not happen. I think there are opportunities with local government, particularly through things like Sure Start. The reach that local government has to communities in very different ways from the Health Service gives a great way of reaching parents who otherwise would not be part of the system and people who are most likely to slip through the traditional Health Service net-the people who might get one of the MMR vaccines, but not all three, for example, or follow up on the course. But it does seem odd, and I agree with Mr Selbie’s evidence: having it as a responsibility of the Commissioning Board rather than the new local authority arrangements I think misses the local flavour of what is needed in order to ensure that it is consistent across the board
Liam Hughes: My experience is that nurses are fundamental in this, and the question is: can you deploy them? When you need to, can you take them off other work that they are doing and make sure they are directed to the response? I think an area that came round very well in a practical example, but after a really worrying time, was on Merseyside in relation to the measles. That shows just how serious this is and why we need to take it very seriously. I do not think I am reassured. Although I know people are working as well as they can locally, personally I am not yet reassured.
Councillor Mary Lea: I think there is an issue about the relationship between councils and Public Health England. I think that needs to be worked through and sorted out.
Q209 Simon Danczuk: What is wrong with it, Mary, just briefly?
Councillor Mary Lea: If we look at health protection, we only found out on Friday that community infection control is coming to the Council. This is very late. It all happens in a few months, and we have only just found this out.
Simon Danczuk: Sure, and we have Christmas in between.
Councillor Mary Lea: Yes, and Christmas is in between, so that takes a couple of weeks out. So we just found out last Friday that comes to the Council. There are also things like TB: whereas the PCT had control of the treatment and management of that, it is now divided between the CCG and Public Health England. It is very difficult to see how that is going to join up. At the same time, directors of public health have to ensure the safety of the community and the safety of the people within Sheffield. When other people have the authority and resources for commissioning these services, it will prove very difficult. So I think those issues do need sorting through, and very quickly.
Q210 Simon Danczuk: You are not assured either, are you, Mary?
Councillor Mary Lea: No, I am not.
Q211 Simon Danczuk: Just staying with you briefly, Sheffield said in its submission "there is still no clarity about how the on-call, out-of-hours cover for health protection will operate". Are you still unclear about that? Do you still have concerns?
Councillor Mary Lea: Yes, we are still unclear about how that will operate and we do have concerns, so we do need some clarity on that. That is urgent, I think, as well.
Q212 Simon Danczuk: My final quick question: the BMA, an important organisation, have raised some concerns. They said, "Current proposals do not address the need to establish an effective health protection workforce at the front line." They also raised concerns that organisations that have a national role will have difficulty tailoring their responses to local plans. How do you respond to that, starting with you, Anthony, just briefly? What do you say to the BMA?
Councillor Anthony Devenish: They are a respected organisation and they have their point of view. What I would like to do is push the whole localism agenda generally and let Westminster decide for Westminster.
Councillor Nick Forbes: The fundamental point I make is we do not know whom to talk to, because Public Health England does not exist yet, apart from in shadow form. So it is not just what conversation do we have, but who do we have it with? I do not know.
Simon Danczuk: Is that proving a real problem?
Councillor Nick Forbes: Yes.
Liam Hughes: Yes, and directors of public health historically have been absolutely instrumental in making this work. I think they need to have that role reinforced, and it is local. The issue is it is local but it spreads over several authorities, so that will be a test of working cooperatively, say, in Greater Manchester or Merseyside or up in the North East.
Councillor Mary Lea: In terms of our Director of Public Health, he should know to whom to go to get some of the answers that we need to clarify these issues, but I think it is proving very difficult for him to get the answers that he needs in order to advise us as a council.
Q213 Mark Pawsey: I would like some views on what success will look like. What measurement criteria would each of you place on the new regime? How do we know whether it is working or not, and are you happy as individual authorities to be called to account for the activity you have done and the results that have been achieved?
Councillor Anthony Devenish: Well, it will be the preventive measures that we decide on in our plan in terms of going forward effectively. We have two overarching main priorities: one, the lifelong health and wellbeing of people in their first five years and then the issue of older preventive work for senior citizens going forward effectively. We are working on various KPIs at the moment. They are under development at the moment.
Councillor Nick Forbes: Nobody has held the NHS to account for the fact that health inequalities have widened over the last two decades, and I think that partly reflects that health inequalities are multifaceted, complicated, and driven by a wide range of factors.
Q214 Mark Pawsey: Alright, I accept that. How are you going to identify the activity that your council does in narrowing that gap?
Councillor Nick Forbes: We are presented with whole options around dashboards and all sorts of indicators. The three that I am going to be watching out for are smoking rates, because half of the health inequality rates are due to smoking, particularly in routine and manual workers, so I will be looking very closely at smoking rates. I will be looking at literacy rates, because leaving school able to read and write is probably the biggest single factor of being able to cope in a modern, complex world. And I will be looking at employment rates and unemployment rates, because being in a job is the best single factor in terms of people’s mental wellbeing and health. So, in amongst the whole cornucopia of options that we have, those are the three that I am going to be looking at.
Liam Hughes: I would add housing and housing conditions to that. I am aware of how complex it is to get this right in terms of attribution-to understand where the effort comes from and where the results are to be found. Looking at it in a very simpleminded way, it is a proxy. I would just like to track that more money is being spent on evidencebased prevention.
Councillor Mary Lea: I think if we wanted to measure the outcomes of public health coming over to the councils, skills, employment and attainment are the best measures of public health outcomes. If you get that right, then people will take responsibility, as we know, for their own health and their own wellbeing. We have to use the resource and the expertise of the public health service to help us get those right. I think you can measure specific interventions and say, "This is an intervention we have used and it has this outcome and it has been good," but that is very small scale. It can sometimes take many, many years for the outcomes that you want to show themselves, and the current climate, whether it is welfare reform or the recession and so on, is going to militate against some of the outcomes that we would like to see.
Q215 Mark Pawsey: We have had a broad range of answers, and, Nick, in an earlier answer you spoke about treatment for alcoholism and the propensity for that. Now, these are all things that Government takes very, very seriously as well, and Government is doing such things. Let us say the Government introduces a minimum price for alcohol, which you are going to be lobbying for. How would you identify what you have achieved and what Government has achieved and, if there is an improvement, are both local government and national government not going to be claiming credit for the same thing? How are we going to isolate what has happened at a local level?
Councillor Nick Forbes: Well, if we have improved health, does it matter?
Q216 Mark Pawsey: Maybe not, but how are we going to measure what you have done? If the result would have been achieved anyway, what has been the input of health and wellbeing boards?
Liam Hughes: I cannot answer that question. I think it might come in in the later session that you are looking at, in terms of what that dashboard might look like from that point of view. These are complex adaptive systems, so if we think we can measure them easily, we are probably misguided.
Councillor Nick Forbes: Absolutely.
Q217 Mark Pawsey: Mr Hughes, you particularly spoke about the amount of money that goes into preventive work rather than treatment. How would you measure that?
Liam Hughes: Well, it is tricky, because the further upstream you go, the cloudier it becomes, because you are really talking about the conditions of life rather than some preventive intervention. But I would look at, for example, whether we are really putting enough money into smoking-whether we are dealing with some of the known conditions that we can make a difference on. You can measure those things, but when you get further upstream it becomes much more difficult to work out.
Q218 Mark Pawsey: Mr Hughes, you also spoke about the specific target to reduce the number of men dying prematurely by 2015 that followed some work from Professor Chris Bentley. How will that local targeted approach work?
Liam Hughes: Sorry, I am not following that. I am not with you.
Q219 Mark Pawsey: You have done some work with Oldham on specific targets to reduce the number of men dying prematurely. How will you set a target on that?
Liam Hughes: Oh yes, that is right. Well, we know what the figure is at the moment. We know what some of the interventions might be able to do-smoking cessation and alcoholrelated and the work of the GPs-and I think there is an element of using best evidence and trying it.
Q220 Mark Pawsey: Going back to your campaigning work, Mr Forbes-and, Mary, you spoke about your council role within public health being to lobby Government-would your electors not just say your job is to get on with delivering good services, not lobbying Government?
Councillor Nick Forbes: Can I give you a specific example on this? Newcastle PCT spends £77 per head on cancer treatment. Currently, it spends less than 50 pence per head on tobacco control and smoking cessation services, and yet all of the evidence is there that comprehensive tobacco control measures make a big difference in terms of rates of cancer. So I think it is entirely legitimate that we would not just look at what we are doing on the ground around tobacco control but lobby for legislative change as well, because we can see the wider benefits that would have in terms of shifting the balance of resources from treatment to prevention.
Q221 Mark Pawsey: Right. Tony, are you going to be spending your scarce resources in public health on lobbying the Government?
Councillor Anthony Devenish: Well, I think you have to communicate. I would not call it lobbying. I would not say it is a contradiction in terms in the way perhaps you may be implying, sir. At the end of the day, you have to get your message across, and the value for money point, which we have just touched on, is that if we can prevent things through reducing binge drinking, that is going to help the NHS overall. I think we all agree with that.
Q222 Chair: One last question: you have all talked about the wider roles and responsibilities that local government have and what they can do with a variety of different mechanisms. You are all responsible, either singly or collectively, for pension funds. Just very briefly, do you all have a policy with regard to public health and your pension funds-say, not investing in tobacco companies?
Councillor Nick Forbes: I know exactly how much money the Tyne and Wear Pension Fund invests in tobacco companies. I think it is completely inconsistent with the policy that we will have around improving health. The fact that £1.6 billion nationally is invested in tobacco companies is a shame on local government, at a time when we are supposed to be improving health.
Q223 Chair: So the answer is you are getting round to it, in due course.
Councillor Nick Forbes: I am very clear that it cannot continue.
Councillor Anthony Devenish: Shall I answer the question next? I was on the Superannuation Committee at Westminster before I became a cabinet member, and we did look into this. You should remember superannuation committees in local government are independent and they would not want cabinet members or, indeed, the leader of the council telling them what to do. They are there to represent the interests of the pensioners.
Councillor Nick Forbes: Except that is where I disagree, because I think we have a moral responsibility to think globally but act locally. When we look at the amount of damage that is done around the world by tobacco, in the 21st century more than a billion people will die from tobaccorelated causes. We have that responsibility, because otherwise the investment that we make in tobacco control at a local level will be far outweighed by the damage that is done internationally.
Councillor Mary Lea: We have the South Yorkshire Pensions Authority of the four leading authorities in South Yorkshire. I do not specifically know what they invest that money in, but I will go back and find out. If we go back many, many years, maybe you could tell us the answer to that one, Clive. I do not know.
Q224 Chair: Thank you. I was chair at one point; thank you for reminding me of that. Perhaps you could let us have a note on that; that would be helpful.
Councillor Mary Lea: Yes.
Liam Hughes: I do not know the answer. I am going to go and find it out when I get back. What I would say is that, within the prime purpose of the pension fund, it would be very legitimate to look much more widely than just at that investment, and to look at how the fund can do some local good. Quite a lot of local authorities have been looking at this through their funds.
Chair: Thank you all very much for coming and giving evidence this afternoon.
Examination of Witnesses
Witnesses: Kim Carey, Corporate Director, Adult Care and Support, Cornwall Council, Councillor Roger Gough, Cabinet Member for Business Strategy, Performance and Health Reform, Kent County Council, Dr Mike Grady, Principal Adviser, University College London, Institute of Health Equity, and Councillor Ernie White, Cabinet Lead Member for Health, Leicestershire County Council, gave evidence.
Q225 Chair: Good afternoon. Thank you all very much for coming to our second evidence session this afternoon. For the sake of our records, could you just go along and say who you are and the organisation you represent?
Councillor Ernie White: My name is Ernie White. I am a county councillor. I am the Lead Member in the Leicestershire Cabinet for health and sport. I also lead one of the Leicestershire districts.
Dr Grady: My name is Mike Brady. I am the Principal Adviser at the Institute for Health Equity at University College London, which was formerly the Marmot Review Team.
Councillor Roger Gough: I am Roger Gough. I am a Member of the Cabinet at Kent County Council and I chair the Kent Health and Wellbeing Board.
Kim Carey: Good afternoon. I am Kim Carey. I am the Corporate Director for Adult Care and Support with Cornwall Council.
Councillor Ernie White: I forgot to say I also chair the Health and Wellbeing Board, Chairman, sorry.
Q226 Chair: Okay, and quite an important thing for this occasion. Just before we begin with questions, I will just thank Roger Gough very much indeed for all the help he gave us with our visit to Kent last week. It was a really excellent visit. Pass on our thanks to your colleagues as well.
Councillor Roger Gough: I will do so, Chairman, thank you.
Q227 Chair: You probably heard some of the discussion with the last witnesses about how there may be some tensions between trying to get some shortterm wins-individual measures that can show the new arrangements have been successful-and the longer term interventions. The latter were referred to as "very upstream" actions; it might take a long time for them to come through or to prove that they are the measures that are having the effect. Do you see that tension and do you see the possibility of resolving it, or will it always remain?
Councillor Ernie White: There is a tension, Chairman, obviously, but I think the trick is to do both, surely. I know from my perspective in Leicestershire we have had some early wins to demonstrate that the partnership working developed by the Health and Wellbeing Board has made it easier to protect the Healthy Schools Programme. It has made it easier to change the focus of the County Sports Partnership to encourage not just sport but physical activity for its own sake across the age range and in family groups. We also managed to lever £1 million of NHS money into district councils for Disabled Facilities Grant work in people’s homes where they have lost mobility, because the NHS saw that as very early intervention and prevention, which is a key priority for the Health and Wellbeing Board.
Councillor Roger Gough: It is important to keep a perspective on short, medium and long term. I heard that Chris Bentley was referred to earlier on and, as some members of the Committee will know, we had him come and speak at our Health and Wellbeing Board in Kent about 10 days ago, and he had a very, very profound effect. One of the things he always emphasises, as many people will know, is that you can look at the very long-term determinants of health and move, if you like, way upstream. You can also come various ways closer to the more immediate term, and, in particular, you can look at provision, for example, and how that serves the people who are, in many ways, in most need. Is there adequate cover for the people who are most deprived and, in many ways, at the biggest risk in terms of health? Those are areas in which you can have an effect in one, two or three years, not five, 10 or 20 years. It is important that you keep an eye on all of those things. Of course there is a trade-off in doing those things. There naturally is, but I think that is part of the normal business of making difficult decisions in local government and in health.
Dr Grady: I would agree with that point. It was not by chance that we called the first report of the global Commission on Social Determinants of Health Closing the Gap in a Generation. Some of this will take us a generation, but equally you also know from the work that we did on Fair Society Healthy Lives that, if we used an indicator of readiness for school at five, we would know within a relatively short period of time whether we were having an impact. If we used the NEET figure, then again we would know within a short period of time whether we had had an impact. So it is about pulling all of those strands together and using proxies where we cannot define evidence immediately.
Kim Carey: I would echo what all of my colleagues have said, but of course be mindful of the fact that we work to political terms as well, and clearly within local government there is an imperative to make sure that we can evidence where our investments are making a very real difference to the people living in our communities. So it is about having that mix of shorter, medium- and long-term effects.
Q228 Chair: In the way you have constituted your Boards, have you reflected on the need to have both the immediate wins, if you like, and the longer term overall strategy, and have you managed to integrate that with the public-health-type work that local authorities have always done?
Kim Carey: I think we have done that very successfully in Cornwall. The work that we have been doing to set up our health and wellbeing strategy has been coproduced with people who are supported within Cornwall. They are very clear that they are going to hold us to account and want to see a very real difference, so we are being driven not only by national targets that we are aware we have to achieve but also by what is important to the people living in Cornwall.
Councillor Roger Gough: If you look at us in Kent, it is true that the Director of Public Health, who is of course a statutory member of the Health and Wellbeing Board, is the only person on our Health and Wellbeing Board with "public health" specifically attached to their name. That said, the public health consultants have played an extremely active role in the agenda of the Board and in developing it over the last year to 18 months. So in that sense-this is something that I suspect we may come to later-as you, Chair, and some others will be aware, in Kent we are moving to more local health and wellbeing boards as well. In those areas, the public health support for it will be significant.
Dr Grady: Locally, I do not have a health and wellbeing board, but I do advise health and wellbeing boards across England on their constitution and arrangements. I say to them that if they are going to address the social determinants of health-the things that really matter are education, transport, housing, and social cohesion within communities-then they are going to have to codesign and coproduce their strategies with local communities and, as importantly, they need to orchestrate the collaborative partnership. Orchestras do not need everybody playing at the same time, but they do need the right players in the room to address the right issue, and it is that dynamic, I think, that needs to be built into the system if it is going to be a bit more than the talking shop that local strategic partnerships became.
Q229 Chair: And are you seeing that happening or do you have concerns it is not happening in some areas?
Dr Grady: It varies quite considerably, as indeed the linkage between strategies and projects to deliver those strategies varies local authority to local authority; practice is very mixed across the country.
Councillor Ernie White: We have been meeting in shadow form now for nearly two years, and I guess recently, in the middle of this year, I, as Chairman, began to feel that the Board was working as a Board and not as a collection of various agencies. That was quite a profound change in the psyche of the Board, and I think it is beginning to show the value of having that kind of organisation, where, as far as we are concerned, the major commissioners sit round the same table at the same time with a common agenda, having had lots of work done in preparation in terms of building up papers for the Board. We have a fairly sound substructure, and I think local people know that they do not have to be on the Board to influence the work of the Board. We have managed to keep the membership tight as well.
Q230 Bob Blackman: Last week we saw at Kent the rather complex arrangements that you have had to make because of the position in relation to the county and the number of CCGs, with the Health and Wellbeing Board having a series of subcommittees coterminus with the CCGs to sign off the strategy and then try to remove any hassle and grief that might result. I am not sure what the position is in Cornwall and Leicestershire in relation to the number of CCGs and the arrangements that you have made. If there are a number of CCGs in your two counties, what arrangements are you making to ensure that you do not get duplication or conflict with the strategies adopted by the wellbeing boards and the CCGs?
Kim Carey: We have a single CCG in Cornwall, which makes it very easy.
Councillor Ernie White: In Leicestershire we have two, neatly sliced east and west, both led by GPs who are extremely good in public, and that helps an awful lot. They are very good in committee. In fact, you would often take them for council officers sometimes-they are that good-and you do not always get that mix with clinicians of being able to work in public at that level, so we are quite fortunate.
Q231 Bob Blackman: Roger, have you given advice to other areas where there is possibly an equally complicated strategy or structure as in Kent?
Councillor Roger Gough: We have not given advice to anyone in particular on it, because we have not been asked for it, as such, but if asked we would give it. As far as I know, Staffordshire is the only other one that has moved somewhat down that route. But we are in a different position from some of the other colleagues around the table because we have seven, and only one of them is completely coterminus with a district.
Q232 Bob Blackman: Just to make it even more complicated, as we saw last week. Dr Grady, you have hinted at the orchestra being conducted in terms of the various different strategies to be adopted. Can you give us any examples of good practice?
Dr Grady: Yes. The example of good practice that stands out to me in terms of orchestrating immediate activity is that of Birmingham City Council. If you look at the figures for Birmingham City Council in relation to readiness for school, what you will find is within three years they shifted that figure from 38% to 55% by having a coherent strategy, agreed joint priorities, integration of services and an absolute focus on what the health outcome was that they wanted to achieve. There are significant other examples up and down the country that leave me feeling optimistic that local government is grabbing hold of this agenda, driving forward with partners in relation to addressing the social determinants of health, and avoiding being dragged back, as has been the history, into lifestyle initiatives, which we know do not work and certainly do not work in the bottom 50% of the social gradient of health. Therefore, I feel very optimistic in terms of collaborative partnership working in the future.
Q233 Bob Blackman: Clearly the agenda moving forward is for adult social care and health coming together, and obviously there is the role of the private, voluntary and community sectors in that. How do you see those coming together to deliver for people in your areas?
Councillor Roger Gough: We have a patchwork of arrangements at the moment across Kent, and I think one of the roles of the Board-and I think this will be for the Kentwide Board to do-is in many ways to help spread that best practice. So we have examples in some parts of the county where you have teams around the practice-very much, if you like, on the provision side-and that has been developing extremely well. Again, you heard a little bit about that from some of my colleagues last week. What we are doing in other parts of the county is focusing quite a lot on the commissioning side, where you have in effect a virtual commissioning team. So what I would see us doing in many ways is building on those initiatives, spreading them bit by bit across the county and ensuring that each of those CCG areas delivers on it, because there is clearly a very strong shared interest for us in that.
Kim Carey: Locally there has been quite a lot of political noise and noise from the public about the role of the private providers, particularly around providing health. Through our scrutiny function we have already pointed out that quite a lot of health is provided by private providers already, who have been trying to provide reassurance. We have a very large private and voluntary sector within Cornwall that offers some very good support to people and we want to build on that, so we are trying to steer that through in a way that does not cause unrest and concern for people.
Q234 Bob Blackman: Are you bringing them into the Health and Wellbeing Board or the CCG?
Kim Carey: We have a stakeholder group that supports the Health and Wellbeing Board. The main membership of the Health and Wellbeing Board are commissioners, but we have a very large stakeholder group. It is one of the very few meetings that I attend that people want to join, but the stakeholder group is informing us and just challenging us and keeping us in check.
Councillor Ernie White: My experience is very similar. In a former life I worked for a local charity, a very large countywide charity, of which there are a number in Leicestershire, and the issue with membership of the Board was where you stopped. In Rutland, for instance, which is fairly small and tight as a county, they have a well established, well respected county voluntary sector body, and the leader of that is accepted as representing the whole of the voluntary sector in Rutland. We do not have that kind of organisation in Leicestershire. So, to repeat, the work of the voluntary sector is very much respected and very much encouraged, and, through the substructures, they do make an enormous contribution. I know we are having a stakeholder event this week on our health and wellbeing strategy. They will all be there and they will all tell us what we are getting wrong and occasionally what we are getting right. But they are very vociferous and extremely welcome in the whole agendasetting arrangements for both the JSNA and the strategy.
Q235 Bob Blackman: Mike, what do you see nationally?
Dr Grady: I certainly want to see a level of coherence around the approaches taken that move us beyond just provisioning commissioning, because this is, yes indeed, a commissioning and provisioning debate, but it is also a debate about local democracy and it is a debate about how we develop and empower individuals and communities and create greater levels of social cohesion within those communities. We know from the evidence that, in those societies where social cohesion is much tighter and much more powerful, it builds health, wellbeing and resilience in communities and people do better. They flourish more and they thrive more, and we should not lose sight of the fact that the primary driver needs to be the empowerment of individuals and communities, and then a range of support services and commissioned services support that activity.
Q236 Chair: Just picking up on that point and what we saw in Kent last week, it seemed very clear there that Kent County Council, as the democratically elected body in the area, was very much seeing itself as taking the lead independent from the strategy. It was certainly working with partners, but it was creating a framework and a lead not merely for public health but for the commissioning groups as well. Did I get it right that you see yourselves in that role-as a key to pulling these things together?
Councillor Roger Gough: I think particularly at this stage, to some extent, yes. I would not overemphasise the point visàvis the commissioning groups, because in many areas it is very much their area of expertise and areas that they will develop in partnership with us, because of the health and wellbeing strategy and so on, but nonetheless it is very much, if you like, their area to lead. What I think is the case-and, funnily enough, this was mentioned at a meeting I was at before I came here, looking at developments across the country-is that because local authorities are mature organisations and have many of the structures in place to do this kind of thing, it is quite natural that many aspects of development and leadership will fall to them particularly at this point. In many ways, I think it is down to them to pick up that particular ball and run with it.
Now, I think you have to be very careful, because everything that we are talking about in this should be about shared leadership, and there is a very easy temptation, perhaps particularly for bodies like ours, to be a bit directive. I think we have to guard against that extremely carefully. But it is natural, I think, just given the shaping of the organisations, because if you look at who is round the table on a Health and Wellbeing Board, CCGs have come into being over the last year or two and are, in the case of Kent, still going through their authorisation process. Healthwatch is still in the process of coming into being, etc, etc. So in many ways I think it is natural that the local authority will take quite an active role in all this. Over time, as some of the other organisations mature, that may well be shared a bit more.
Q237 Simon Danczuk: I wanted to ask about funding. I notice that Leicestershire County Council, Ernie, said a significant issue of concern is the budget. The final allocation for 201314 is due to be announced on 19 December. A budget pressure in excess of £1 million is anticipated. Cornwall Council explained it has been challenging to manage preparedness without knowing the full extent and impact on resources. Not knowing the budget then yet and whether it will be £1 million or not, how much of a problem is this creating, Ernie?
Councillor Ernie White: It is a problem not just for the public health budget; it is a problem for all the partner organisations. We had a session last week about joint commissioning, asking partners where they were with planning their commissioning around the JSNA priorities. They were all saying, "We do not know our budget. Of course, we will commission together, but until we know where we are with our budget, we really cannot get into a positive mood about sharing." So the sooner we get our allocation, the better. If it is £1 million, as we expect it to be, we will have to manage that through 2013, because there is a reputational issue. If, on vesting day, as it were, there were huge cuts in public health budgets when one of our priorities is prevention, it would look silly. So we have made plans to cover ourselves over certainly the 201314 budget and, hopefully, we can manage some of the costs down through better procurement and commissioning. We may be able to find some reserves, although when you talk about reserves in local government these days, people give you a strange look. But there are always little pockets that you can work at, and we have to be very swift on our feet to make sure we do not have any embarrassments from next April.
Q238 Simon Danczuk: Mike, do you have a view on the lateness with which budgets are being set?
Dr Grady: I certainly do, and I have a view about the 4%. 4% as a proportion of the budget spent on public health is one of the lowest proportions within the OECD. A clear recommendation in our review was that that figure should increase significantly as time moves forward. The lateness of it does not help either. Most of that 4% is linked into public health service delivery, and therefore creates anxieties both for staff involved and for the organisations involved. There is an interesting debate to be had about the 4%, but what really interests me is how we are going to spend the rest of the money on addressing the social determinants of health in relation to early years education, our young people who are unemployed and not in training, our people who need support in terms of communities, and our older people. It is that kind of spend that needs to shift into a public health agenda rather than provision.
Simon Danczuk: We are going to come on to that.
Councillor Roger Gough: I think there are two or three elements. Firstly, as was mentioned earlier on, there is uncertainty about public health budgets and there is uncertainty about total budgets. We confront both of those, and that should be clarified sometime between now and Christmas, but it is extremely late in the day.
Q239 Simon Danczuk: What impact does that lateness have for you as a local authority?
Councillor Roger Gough: It naturally means that you have to think long and hard about the priorities that you have set. When you have engaged, as we have, in public consultation and debate around "this is how we see things going", and then, thinking here about the wider budget, you see the prospect of further reductions in Government grants at the last minute, it makes that difficult.
As far as public health is concerned, I think there is a short-term and a long-term issue. The short-term issue for us is much the same as has been discussed already. In our case, we look at what we believe has been spent on the equivalent services this year, and that is just over £43 million. The minimum guaranteed, from what has been said so far, is £36 million, and we are not quite sure where between those two it is going to end up.
Leaving that to one side-and that is obviously a major issue this close to the whole system change in spring next year-there is the longer term question, which is: what happens to public health over time in terms of the allocation of funds across the country? Obviously, what has happened so far is very much built around existing patterns of spend by PCTs, and in some parts of the county there was a historic pattern of underspending, and of those areas being the victim, if you like, of the last minute dash to balance the budget. The end result of that is that, if we look at what we get on a historic basis compared with what we think a needsbased analysis would be, the latter would work in our favour. The question of how quickly one might move towards that, given that the Government understandably does not want any area to lose out and we know what the overall constraints on spending are, is a long-term challenge for us, because it means we suspect we will not get what we would otherwise expect to get and think would be good for delivering what we need to.
Q240 Simon Danczuk: Kim, you have to organise these services and make them work, and you are going to know how much you have to spend at the last minute. What is the impact?
Kim Carey: We are flagging the budget transfer high on our risk programme, and it is becoming more of a risk the closer we get to the transfer of the service. I think the biggest risk is to those people who have been providing services through contracts with the PCT. We are unable to issue those new contracts or have any reasonable debate with those providers because we do not know whether we will have the resource to enter into new contracts with them. Whilst it is a risk to the Council, the larger risk is to those people who have been delivering services in the past.
Q241 Simon Danczuk: Do you mean local voluntary organisations that are dependent on funding and things like that?
Kim Carey: Yes, and some of the other health trusts that deliver services.
Q242 Bill Esterson: On this point, Ernie, you made the point about vesting day, and, having been through local government reorganisation many years ago, it has a profound effect on the management of services if not necessarily on the delivery. That disruption to management can then have a disruption to service delivery. Kim, you were touching on that in your risk assessment. To what extent is that planning going on regardless of the issue about uncertainty over budgets?
Councillor Ernie White: The planning is going on, but we are kind of holding our breath. As I said earlier, if we are a million short, we intend to manage that through to next April or May and through next year, and we will get down to the hard yards, if you like, about managing within the allocation throughout next year. It is bound to mean some change and it is trite to say we can get more for the same, but we have been doing it in local government now in a heavy way for the past two or three years, and we are learning the tricks of getting more out of the same pounds spent. No doubt when we apply that kind of expertise to the public health budget, we will make some more savings.
Q243 Simon Danczuk: Mike, I particularly wanted to come to you. In the long term, is a transition from ringfenced public health funding to placebased funding desirable, logical and inevitable?
Dr Grady: I would have thought so, absolutely, and the evidence supports it. If you go back to the total-place pilots that we looked at, they were very good examples of greater efficiencies, savings, engagement of communities, and coproduction of services with people and communities. It is the place to go. In the meantime, I do believe that in the shorter term, whilst the transition takes place, we do need a ring-fence to protect the public health spend and make sure that we can maintain particularly the preventive services within public health. That is a really important issue, but placebased budgets are the way to go in the longer term.
Simon Danczuk: Any other quick comments on that before I move on to the final question?
Councillor Roger Gough: I absolutely agree with that distinction between short term and long term. I think that is absolutely right.
Q244 Simon Danczuk: My final question: drug misuse and sexual health services account for 50% of public health funding. Do you envisage any political problems with this, Ernie, Roger? It is quite up front, is it not? The public are probably not aware of that, are they? You guys are politicians. Are you going to be out there shouting about where you are spending half of your cash?
Councillor Roger Gough: Well, I do not think we are going to seek to obfuscate about it, but so far that has not been an issue, I would say. There has been no evidence of that as an issue at all for us. What has been the case is that we have been going through a process of discussing, certainly in very public forums and in our own Health Overview and Scrutiny Committee and other such things, what the public health budget embraces. Sometimes you get some interesting reflections about which demographic it is looking after: how much of this service is focused on younger people and whether there should be more focus on older people-that kind of thing. But I do not think there has been any evidence so far of difficulty on the specific area that you describe. If it comes, we will have to deal with it as it arises, but there is no evidence so far.
Councillor Ernie White: Didn’t someone use the phrase the "oxygen of publicity" regarding certain issues? I think the more we share with the public what it is costing to deal with some of these lifestyle issues, the more they are prepared to accept change in the way of a minimum price for alcohol. That kind of national change might be better accepted once the public know the full cost of trying to deal with the consequences.
Simon Danczuk: That is a good point. Are there any points from Kim or Mark on that? No? Thank you.
Q245 Andy Sawford: Given the time, I hope you will not mind if I ask some direct questions. In the first instance, can I ask Roger and Ernie for a simple yes/no? On your main Health and Wellbeing Boards, so I am not talking about substructures and so on, are district councils represented?
Councillor Ernie White: Yes.
Councillor Roger Gough: Yes.
Q246 Andy Sawford: In what form? How many representatives are there and how are they elected to represent the districts?
Councillor Ernie White: In Leicestershire, we have a district leaders’ forum, where the district leaders meet every so often, and we use that forum for nominations for membership of the Health and Wellbeing Board. So there is a twoway dialogue between district leaders and their Board representatives. One is a district leader and, in fact, because I am a district leader as well, on our Board there are three district councillors.
Q247 Andy Sawford: Roger, come in on the point about the composition, but how important do you consider that district council representation?
Councillor Roger Gough: It is absolutely essential. We have 12 districts in Kent. We went for three district council representatives on the Board. As I mentioned earlier, the substructure plays an important role in the district contribution as well, but, in terms of the main Board, there are three, chosen by a mechanism very similar to what Ernie described. As it has worked out, it represents west, east and middle, which is perhaps as much luck as judgment. It has been down to the district leaders themselves to choose.
Q248 Andy Sawford: Given the clinical commissioning groups have a statutory role, and given the importance, you believe, of district councils participating, looking at the evidence the Committee has had from the District Councils’ Network, who note that discrepancy and also say, "The lack of statutory recognition for districts has contributed to some unnecessary local confusion over the role of district authorities," and that that has "in some cases affected the adequacy of local preparations", would you support a statutory role for district councils on health and wellbeing boards?
Councillor Ernie White: It should not be necessary, I do not think. One essence of the change is that these things will be decided locally. Why tell them what to do? Let them sort out these issues, these conflicts, locally. What we have done in Leicestershire appears to work. We have enthused the district council as well, because these two representatives also link with what we call a local health forum within each district. Each district has its own health champion. They have their own very localised programmes for public health issues, and the public health staff visit on a regular basis to sit inside the district council buildings and work with district council officers. I do not think we needed to be told to do that as far as Leicestershire is concerned. That has happened naturally.
Q249 Andy Sawford: That sounds like an arrangement that is working, and Roger might comment on whether he thinks a statutory duty is needed, but the experience of county areas is obviously different, because the District Councils’ Network say, "In some county areas, there continues to be reluctance to have sufficient representation on boards (including voting rights) or to effectively communicate HWBs developments and the role of district councils locally." So whilst you may have effective arrangements, they are making an argument for statutory recognition. I am going to ask Mike in a moment, but what is your view on the statutory point, Roger?
Councillor Roger Gough: I would be reluctant to see further prescription, though I say from a Kent point of view we would not have any objection because we do it already, but I suppose I instinctively lean a little bit against yet a further bit of statutory prescription.
Q250 Andy Sawford: Mike, do you see differences around the country?
Dr Grady: I do see differences, but if there are a set of relationships that mean that you cannot sit round the table and take concerted joint action, then I do not believe a statutory requirement is going to change that. It seems to me the partnerships that work most effectively are those where there is a network of relationships that allow people to trust each other and do, not sit there because they have a statutory requirement to do so.
Q251 Andy Sawford: The Committee is interested in the role that housing has in your assessment of strategies. I wonder if you would, given the hour, say something briefly, and if you have any further evidence, perhaps you might send it to us; I am sure it would be welcome as well. Kim, what role does housing have in your strategies in Cornwall?
Kim Carey: It is absolutely fundamental. What we recognise is that health and wellbeing is not just about people’s health and their social care. It is about where they live; it is about the relationships they have; it is about how they live within their communities and the value that they both give to and get from that community. Housing is an absolutely vital strand within our strategy.
Q252 Andy Sawford: Have you anticipated changes in the coming months due to the effect of the Housing Benefit reduction, the Council Tax Benefit reduction, the Universal Credit, and the likely increase in homelessness that some organisations are predicting? Have you put in place strategies through the Health and Wellbeing Board?
Kim Carey: Yes, we have. We have had a number of presentations. In fact, we had one just last week updating us, and it is of great concern to the Health and Wellbeing Board. We are making sure that every opportunity is taken to look at the likely impact and minimise the impact of the welfare changes on the population. We know it is going to hit those who are most in need.
Councillor Roger Gough: If I could just add something that fits in with what Mike mentioned about relationships, I think a key element of how we approach housing is that we already have a thing called the Kent Housing Group. It has a whole series of offshoots, which brings the districts, the county and, indeed, Medway, our neighbouring unitary authority, together, along with a whole number of other players in the housing sector, to try to look at housing from a strategic point of view. A number of their streams of work link in to what is in the health and wellbeing strategy and what is already in the Health Inequalities Action Plan that we have. So, for us, housing is very, very important, and that is one of the key things that the districts bring to the table.
Councillor Ernie White: I agree with that.
Dr Grady: It makes me very excited to see urban planning and the planning of our cities’ housing come to the centre of this agenda, because they have needed to for a long time. It is okay talking about smoking and alcohol and what have you, but what we know is the places where people live are critically important to their health and wellbeing. If you are happy with the area in which you live, you are 200 times less likely to have a mental health problem. They are really important issues, and they need to come to the fore in terms of encouraging greater levels of activity, greater levels of social cohesion within communities, and greater levels of support networks, because it is those support networks that help people to flourish.
Q253 John Stevenson: Just very quickly, Ernie and Roger, you have three district councillors on your Board; how many county councillors do you have on your Boards?
Councillor Roger Gough: Four.
Councillor Ernie White: Three.
Q254 Mark Pawsey: I would like to ask about how scrutiny is going to work under the new arrangements post-April 2013. Within the councils themselves, councils now have responsibility for delivering health services. How is that going to affect the scrutiny? That is probably particularly a question for Ernie and Roger, who are from county councils.
Councillor Ernie White: I sense, in Leicestershire anyway, that scrutiny has been reenergised by this agenda.
Q255 Mark Pawsey: Because councils can do something about it now.
Councillor Ernie White: Well, yes, but the Health and Wellbeing Board is not a balanced political arena. Because it will be a subcommittee of the Cabinet come next April, there are no Opposition members on it, so the Opposition argument, debate, discussion goes into scrutiny. They have done some really, really good work this year, and they know they have my commitment and support, and I go when I am invited; I am not allowed to go unless I am invited, because, apparently I scare them. I do not know why, but they are shrinking violets, I am told; anyway that is an aside. The work of scrutiny, I think, will be enhanced by this new agenda.
Q256 Mark Pawsey: Roger, have you found the same thing in Kent?
Councillor Roger Gough: Yes. When the White Paper first came out, you will recall that the suggestion was that somehow the scrutiny role could be collapsed into the Health and Wellbeing Board, and we, like many others, made representations to the Government to say this was a very bad idea. The end result, as you know, in the Act is that there will still be a scrutiny committee arrangement of some kind for the local authority. Our view, I think, is if it looks like a HOSC and it quacks like a HOSC, then it is a HOSC, and so it will continue. Now, what it will do, I think, is two things. Firstly, it already does a great deal in terms of looking at providers-and remember the reform widens that function, in that anything funded by an NHS pound, if you like, can come within the HOSC’s frames of reference.
Q257 Mark Pawsey: Sorry, could you just explain "HOSC"?
Councillor Roger Gough: Health Overview and Scrutiny Committee. I do apologise.
The second thing is that we have already been bringing forward a number of the major initiatives, and it sounds as though Ernie is doing something very similar. As we have been bringing forward our work on Healthwatch, as we have been bringing forward our health and wellbeing strategy-a whole number of the staging posts towards the implementation of the reform-we have been taking that to the HOSC. I think that we see them, over time, holding us, the Board, to account for the outcomes that we seek to achieve. So a major function that they will have, quite apart from what they see visàvis the providers, is to look at the Health and Wellbeing Board and whether it is doing its job in terms of delivering those outcomes that it set itself.
Q258 Mark Pawsey: And Mike and Kim, how do you see scrutiny working out?
Kim Carey: There is a healthy debate going on between our Health and Wellbeing Board and the scrutiny function at the moment. I think there are still some issues to be resolved as we move forward.
Dr Grady: I think it is a triangle of the Health and Wellbeing Board, Healthwatch and the Overview and Scrutiny Panel, and I think the development of those relationships will be critical. There is a change in focus away from providers and the NHS and acute beds into the social determinants of health, and there is some good evidence that the work the Centre for Public Scrutiny has done over the past couple of years with overview and scrutiny panels has allowed that to happen. I was reading only yesterday a report from Leeds Overview and Scrutiny Panel that was looking at how to generate employment within Leeds. That is the kind of activity that we need to see coming forward, but we also need to hold the health and wellbeing board to account for what is in its JSNA and that what is in its JSNA is driving the priority for the health and wellbeing board.
Q259 Mark Pawsey: But we are not very far away from the reforms and there is still some uncertainty about the role of Healthwatch. I think, Kim, in your Council’s submission you said, "It is unknown how the role and relationship with local Healthwatch will unfold." I do not know when that was written, but are you any clearer now?
Kim Carey: I think we have moved significantly closer to getting an outcome. We are hoping to complete the process for setting up a new Healthwatch very soon, so we have gathered pace.
Q260 Mark Pawsey: But it is not yet in existence. We have had shadows on councils for two years, but Healthwatch is due to take over the scrutiny role in just a few months’ time. Nothing is in place in Cornwall.
Kim Carey: No.
Q261 Mark Pawsey: What is the situation, Mike, across the rest of the country?
Dr Grady: It is very variable. Personally, I feel very sympathetic towards Healthwatch. We have been through CHCs, LINks, Public and Patient Forum, Public and Patient Involvement and now LINks transforms itself into Healthwatch. I think there is a great deal of uncertainly, a great deal of confusion and, frankly, disillusionment about the seriousness of putting patients and the public at the centre of these reforms.
Q262 Mark Pawsey: Mike, you have given a lot of advice to councils on LINks. Do LINks simply morph into Healthwatch? What happens?
Dr Grady: No, it is not as simple as that. It will be quite variable. In some cases they will do that; in other cases there will be a tendering process and a commissioning process, and it is quite a variable position across the country. This again builds into the uncertainty, because a legacy of LINks need to transfer over if we are going to maintain good public involvement in relation to the health reforms.
Q263 Mark Pawsey: Will Healthwatch cover all services and all groups, and what is going to happen if there is a gap?
Kim Carey: We anticipate that it will cover all services and all age groups.
Q264 Mark Pawsey: Alright. What if you have a vulnerable group who have a complaint? How will they get that through to somebody like Healthwatch? Who is going to be their advocate?
Kim Carey: Our tendering process ensures that Healthwatch will respond to anybody who needs their support. So we are trying to move away from client groupspecific or condition groupspecific needs and look at the needs and demands of people who use health or social care services.
Q265 Mark Pawsey: What is Healthwatch looking like in the areas of the two county councillors here?
Councillor Ernie White: We are out to tender for the new Healthwatch. We worked with the LINks representatives on the tender document. We intend to have the new Healthwatch in place for 1 April.
Q266 Mark Pawsey: Do you expect to achieve that?
Councillor Ernie White: We will, yes. Yes, that will happen. We have some work to do on writing up some protocols about who does what and who is responsible for what, because there is a degree of overlap, but Healthwatch is independent. It is patientcentred rather than a generality of service for the public. LINks are frequent visitors to the Overview and Scrutiny Committee. They work together to get us. They do work together, and as long as we can get the protocols right, I think there is a powerful duality there in the overview and scrutiny position, both of the Health and Wellbeing Board and of the system in general.
Q267 Mark Pawsey: Roger, we are more aware of what goes on in Kent as a consequence of our visit, but I am not sure we spoke about Healthwatch when we were there.
Councillor Roger Gough: We did a little, I think, but perhaps I can go into a little bit more detail. We too are out to tender. We hope and expect to award very early in the New Year-in January. I think, and I suspect this is true across the country from all I hear, there is a distinction between having the body there and established formally, and it being, if you like, allsinging, alldancing, delivering all that it is expected to. Therefore, my view is that if you have, say, a threeyear contract, which we will be managing with our successful provider, I think that will turn into very much a game of two halves. For the first year to 18 months, our relationship with that body will be one as much of nurturing, support and development as it will be hardnosed contract management, which I think we will move more towards in the second half of that threeyear period.
First of all, we took stock of where we were visàvis the LINk, Healthwatch and so on. Relatively early on, about 18 months ago, we had a process working with the Centre for Public Scrutiny, a socalled "readiness review": what we were doing well in Kent, what we were doing not so well, how we could develop, etc. Earlier this year, we had a couple of sessions with the voluntary and community sector, and that was designed to do two things. One was to draw on their thinking about the kind of models that might evolve for Healthwatch, and that has helped shaped the tender document that we have put out. The second was obviously to drum up potential interest in that as well. Obviously, who bids is ultimately down to them, but we certainly sought to engage with as much of that sector as possible to see who else might well be bringing forward some interest in helping shape Healthwatch.
Q268 Mark Pawsey: Are you satisfied that all services and all user groups will be covered? Is there going to be some little service in a corner that might be overlooked or neglected?
Councillor Roger Gough: Certainly, we have set our tender in terms that would seek to preclude that. A key thing that we have is an outcomes framework by which we will judge the successful bidder over time, and that would certainly embrace both relationships with the whole network of the voluntary and community sector and also the key acid test: do the people of Kent know it is there?
Q269 Chair: Just turning to the question I asked at the end to the other witnesses, does your public health strategy for your area include the investment strategy of your pension fund, and have you, for example, decided not invest in or withdraw investment from tobacco companies? Could I have a short answer from each of you as to how you are thinking on this?
Councillor Ernie White: A very short answer, Chair: pass. I will write to you, but I do not think so.
Councillor Roger Gough: We have debated on it and we have not withdrawn that at present. I fully heard what was said about this earlier on in the discussion and take the point entirely. I think there has been a genuinely difficult trade-off between that and the value of the fund and the pressures on the finances in that connection. That has been the dilemma we have had to face.
Kim Carey: We have had the same debate and have time and again come back to the fact that it is an independent body that makes those decisions on behalf of the pension fund, so it is a knotty issue.
Q270 Chair: Mike, you probably do not have a position to report, but you might have a view.
Dr Grady: I certainly have a view, and it would be an ethical view in relation to addressing the social determinants of health and what is our priority. We cannot, on the one hand, say we are investing in our pension funds but on the other allow them to invest in services that will undermine the public’s health.
Chair: Thank you all very much indeed for coming and giving evidence today.